Clinical Denials Coordinator - Wayne UNC Health Care : Job Details

188890 Job Description *Description* Summary:Coordinates and leads all clinical denial processes and clinical audit activities. Supervises and collaborates with teammates involved in the denial process. Reviews all denial requests and leads the team in the strategy to appeal all clinical denials. Provides the clinical expertise to draft the first and second levels of an audit appeal. Works collaboratively with the Physician Advisors and subject matter experts for all audit and appeals work activities. Assists with documentation review to support the clinical documentation specialistsResponsibilities:1. Provides leadership, clinical expertise and organization to the Denials Management Team within the clinical documentation team. 2. Stays up to date and proactive with all ongoing information, rules and regulations, Medicare and other payor regulations. 3. Reviews all denials and is key point person for assigning team review. i.e. denials to Coding Supervisor. 4. Reviews and documents findings on all medical necessity and status denials. 5. Works closely with Patient Financial Services for issues related to reimbursement, denials, status, etc. 6. Evaluates clinical denials for validity and probability to overturn, proactively gathers required clinical documentation and formulates appropriate appeals. Coordinates the denial team in order to establish appeals plan based on the type of denial. 7. Conducts case studies for those complex denials in order to plan appeal strategies and to educate peers. 8. Conducts pertinent discussions with auditors and follows appropriate appeals process within established timeframes. 9. Reviews and responds weekly to status issue queries from coders, Quality and other entities. 10. Responsible for summary reports of Wayne UNC Health Care denials. Presents denials summary to IM/UR committee bi-monthly and as needed. 11. Reports out at the monthly denial prevention committee on status of at-risk dollars and appeal win rates. 12. Assists in documentation review in the clinical documentation specialist role when needed. Working with Clinicians and Coders to successfully implement documentation review for MS-DRG and AP-DRG payers on assigned Hospital Units. 13. Works closely with the Clinical Documentation Specialist Lead to develop provider and CDS education based on denial results. Other information:Education Graduate of an accredited program for professional nursing.Bachelor's degree in Nursing preferred.Licensure/Certification Current North Carolina nursing licensure.Experience• Minimum 3-5 years of applied clinical experience as a Registered Nurse required.• 2 years utilization review, care management, or compliance experience preferred.• Minimum 1 year clinical denials management preferred.Knowledge, Skills and Abilities• Solid knowledge and understanding of provider reimbursement methodologies, medical terminology, and hospital and physician billing.• Knowledge of government and non-government clinical denial and appeal procedures.• Ability to investigate, analyze and apply billing, medical and reimbursement guidelines.• Coding experience helpful.• Ability to understand and analyze patient bills and medical records. Ability to lead, guide and motivate others.• Ability to read, write and communicate effectively in English.• Proficient with MS Office and able to learn new software rapidly. Experience with EMR (Epic) software desired. Valid NC Driver's License: NoIf driving a Wayne UNC Vehicle, must be 21 years old and MVR must be approved by Risk Management.BO-205 *Job Details* Legal Employer: Wayne HealthEntity: Wayne UNC Health CareOrganization Unit: Health Information Mgmt Work Type: Full TimeStandard Hours Per Week: 40.00Work Assignment Type: RemoteWork Schedule: Day JobLocation of Job: WAYNE MEDExempt From Overtime: Exempt: Yes []( []( []( [](Share your talents and grow professionally when you join the UNC Health Wayne team. As a teammate of UNC Health Wayne, you will work with other dedicated health care professionals and support staff who are passionate about delivering high-quality patient care and superior patient experiences. Why You'll Love Working at UNC Health Wayne Make a positive impact and change lives when you work at [UNC Health Wayne]( one of Wayne County's top employers. Become part of a team working to improve the health and wellness of our community and we'll help support you. Consider the benefits of working at UNC Health Wayne:* Advanced technology for better patient care close to home* Compassionate, community hospital serving people you know* Comprehensive [employee benefits]( for you and your family* Competitive pay* Positive [teammate interactions]( and supportive working relationships* Professional growth and development opportunities